Neurogenic bladder is a disorder which occurs in spinal cord diseases such as spina bifida and is characterized by an inability of the nervous system to properly control the urinary bladder and the muscle tissue contained in the bladder wall. This can lead to spasms and a build-up of pressure in the bladder, often resulting in urinary incontinence. Children with spina bifida and neurogenic bladder often feel urges to urinate after drinking comparatively small amounts of liquid and they can also involuntarily leak urine. This is a source of a lot of emotional stress, especially in social settings such as when they are around friends or in school. If untreated, the long-standing and frequent pressure build-up in the bladder can have even more devastating effects such as infections or kidney damage.

Current treatments for neurogenic bladder involve surgeries which reconstruct and increase the size of the bladder by using tissue patches obtained from the bowel of the patient. Since such a gastrointestinal patch is derived from the patient’s own body, it is less likely to elicit an immune response and these intestinal tissue patches tend to be strong enough to withstand the pressures in the bladder. Unfortunately, the incompatibility of intestinal tissue and bladder tissue can lead to long-term complications, such as urinary tract infections, formation of urinary tract stones and in some rare cases even cancers. For this reason, researchers have been searching for newer safer patches which resemble the actual bladder wall.

A team of researchers at Northwestern University recently published a study which used stem cells of children with spina bifida to generate tissue patches that could be used for bladder surgery. In the paper “Cotransplantation with specific populations of spina bifida bone marrow stem/progenitor cells enhances urinary bladder regeneration” published in the Proceedings of the National Academy of Sciences (online publication on February 19, 2013), Arun Sharma and colleagues isolated two types of cells from the bone marrow of children with spina bifida: Mesenchymal stem cells (MSCs) and CD34+ cells (stem and progenitor cells which usually give rise to blood cells). They then coated a special polymer scaffold called POC with the cells and implanted this newly created patch into a rat bladder after performing a bladder augmentation surgery, similar to what is performed in patients with spina bifida. They then assessed the survival and formation of human muscle tissue on the implanted patch. When both human cell types (MSCs and CD34+) were combined, more than half of the implanted patch was covered with muscle tissue, four weeks after the implantation. If they only used CD34+ cells, they found that only a quarter of the patch was covered with muscle tissue. What is even more remarkable is that in addition to the newly formed muscle tissue, the implanted patch also showed evidence of some peripheral nerve growth and of blood vessel formation, both of which are found in healthy, normal bladder walls. These findings suggest that a patient’s own bone marrow stem cells can be used to help construct a tissue patch which could be used for bladder augmentation surgeries. The observation of some nerve growth in the implanted patch is also an exciting finding. One could conceivably try to re-connect the reconstructed bladder tissue with the main nervous system, but its success would largely depend on the severity of the neurologic disease.

One has to keep in mind that there are some key limitations to this study. The authors of the paper believe that the newly formed muscle tissue on the implanted patches was all derived from the patients’ bone marrow stem cells. However, there were no experiments performed to convincingly demonstrate this. The authors report that in previous studies, merely implanting the empty POC scaffold without any human stem cells resulted in 20% coverage with muscle tissue. This suggests that a big chunk of the newly formed muscle tissue is actually derived from the host rat and not from human stem cells. The authors also did not compare the effectiveness of this newly formed stem cell patch to the currently used intestinal patches, and there is no assessment of whether the newly formed muscle tissue on the reconstructed bladder is less prone to spasms and involuntary contractions. Lastly, all the in vivo testing of the tissue patches was performed in rats without neurogenic bladder and it is possible that the highly successful formation of muscle tissue may have been diminished if the animals had a neurologic disease.

A second study published in PLOS One took a different approach. In “Evaluation of Silk Biomaterials in Combination with Extracellular Matrix Coatings for Bladder Tissue Engineering with Primary and Pluripotent Cells” (online publication February 7, 2013), Debra Franck and colleagues describe how they coated a scaffold consisting of silk threads with extracellular matrix proteins such as fibronectin. Instead of using bone marrow stem cells, they converted induced pluripotent stem cells into the smooth muscle cells that are typically found inside the bladder wall and placed these newly differentiated cells on the silk scaffold. The induced pluripotent stem cells (iPSCs) used by Franck and colleagues can be generated from a patient’s own skin cells which reduces the risk of being rejected by a patient’s immune system. The advantage of this approach is that it starts out with a pure and truly pluripotent stem cell population, which is easier to direct and control than bone marrow stem cells. There are also a few important limitations to this second study. Franck and colleagues used mouse pluripotent stem cells and it is not clear that their approach would necessarily work with human pluripotent stem cells. They also did not test the function of these differentiated cells on the silk scaffold to check if they actually behaved like true bladder wall smooth muscle cells. Unlike the first study, Franck and colleagues did not evaluate the newly created patch in an animal model.

Both studies are purely experimental and much additional work is needed before they can be tested in humans, but both show promising new approaches to help improve bladder dysfunction. It is heartening to see that researchers are developing new cell-based therapies to help children and adults who suffer from neurogenic bladder. The results from these two experimental studies are still too preliminary to predict whether cell-based therapies can be successfully used in patients, but they represent important first steps.

Amphibians such as frogs or salamanders have a remarkable ability to regenerate amputated limbs and tails. The regenerative process involves the formation of endogenous pluripotent stem cells, which then expand and differentiate into the tissue types that give rise to the regenerated body part. The complex interplay of the cell types and signals involved in this regenerative response to the injury are not fully known and there is considerable interest in identifying all the necessary steps. The ultimate hope is that by identifying the specific mechanisms of injury response and regeneration, one might be able to activate similar repair processes in humans, who lack the extraordinary regenerative capacity of amphibians.

The recent paper “Amputation-induced reactive oxygen species are required for successful Xenopus tadpole tail regeneration” by Nick Love and colleagues published online in the journal Nature Cell Biology on January 13, 2013 elegantly demonstrates that reactive oxygen species (ROS), also known as oxygen radicals or oxidants, play a critical role in the regeneration of amphibian tails. Using a rather elegant approach, the researchers generated Xenopus tadpoles with a genetically integrated sensor of the oxidant-sensitive protein HyPerYFP that emits fluorescence upon contact with ROS, and is thought to be rather specific for the oxidant H2O2, more commonly known as hydrogen peroxide. This allowed them to study the hydrogen peroxide levels in all cells of the live tadpole, while it was responding to an injury. They found that within 6 hours after the tail amputation, the residual tail tissue was flooded with high levels of the hydrogen peroxide and that as the tail started growing back, the regenerative edge of the growing tail continued to show high levels of this oxidant.

After excluding the possible confounding phenomenon that the increase in ROS was merely a bystander effect of increases in inflammatory cells, the researchers then performed a pivotal set of experiments in which they used anti-oxidants to see if these would impact the tail regeneration. The researchers first utilized pharmacological inhibitors that reduce the production of oxidants as well as the therapeutic antioxidant MCI-186 (its trade-name is Edaravone and is marketed for use in patients in Japan). These pharmacological agents were all very effective in terms of lowering the hydrogen peroxide levels in the regenerating tail, but they also significantly impaired the regeneration itself. In another intriguing set of experiments, the researchers treated the tadpoles with these agents immediately after the injury and then withdrew them after three days, to see if the regeneration would set in after their removal. Interestingly, when the tails were exposed to agents that prevented the generation of the oxidants, the regenerative program remained blocked even when they were removed. On the other hand, the antioxidant scavenger that soaks up oxidants being produced did not permit regeneration while it was present, but regeneration resumed after the antioxidant was removed.

The researchers also performed complementary genetic experiments in which they reduced oxidant revels by suppressing the enzymes that produce oxidants. The results all point to an important conclusion: There is a burst of oxidants that are released after injury and that are necessary to initiate the regenerative program. The exact molecular targets of the oxidant hydrogen peroxide that enable regeneration remain unknown, but some of the data in the paper points to the Wnt protein pathway as a potential oxidant-sensitive regenerative signal in the tadpole tail.

One has to bear in mind that this work was performed in tadpoles and may not be necessarily fully applicable to the human setting, but Wnt is a key regulator of stem cell renewal, differentiation and regeneration in human tissues. This does suggest that there may be some key similarities between the tadpole regeneration pathways and those found in humans. Despite the shared Wnt signals in tadpoles and humans, building a bridge from this work in Xenopus tadpoles to research and therapeutic applications in humans will be quite challenging. After all, the elegance of this study lies in the genetically integrated oxidant sensor that allows live tracking of oxidants as well as the fact that tadpoles can regenerate whole limbs and tails. Current tools do not permit real-time tracking of human oxidant levels in tissues and humans can usually only regenerate very small amounts of tissue, such as superficial skin injury.

Nevertheless, this work is an important milestone in understanding the role of oxidants as promoters of regeneration and it is very likely that at least some similar pro-regenerative role of oxidants may also be present in human tissues. One of the most important take home messages of this work is that we need get rid of the common “oxidants are bad guys and antioxidants are good guys” myth. Oxidants can be harmful in some context, but they can also serve as important regenerative signals. Indiscriminate use of antioxidants can actually impair these important endogenous signals. Instead of consuming large quantities of non-specific antioxidants, we need to use antioxidants in a very targeted, context-specific and perhaps time-limited manner so that they only prevent oxidative damage without affecting beneficial oxidant signaling.

Two kinds of sweat glands are present in the human body. Apocrine sweat glands are located in arm-pits or rectogenital areas and are responsible for “smelly” sweat. Eccrine sweat glands, on the other hand, are distributed all over the human body and produce a non-odorous sweat. The eccrine sweat glands are primarily found in humans and certain primates. They also exist in some other mammals, but are usually restricted to the footpads of non-primate mammals. There is some controversy about the actual purpose of eccrine sweat glands in humans. The functions traditionally ascribed to eccrine sweat glands include promoting grip, generating a protective acid mantle for the skin as well as regulation of temperature or the electrolyte balance.

The recent article “Eccrine Sweat Glands are Major Contributors to Reepithelialization of Human Wounds” published in the American Journal of Pathology by Laure Rittié and colleagues proposes a novel and very interesting function for eccrine sweat glands. In this study, CO2 laser treatment was used to create superficial wounds in human subjects, either on their palm or on their forearms. The researchers performed biopsies during the subsequent days to assess the wound healing process. They observed significant proliferation of cells at the bases of hair follicles (pilosebaceous units) as well as proliferation of cells within the eccrine sweat glands. The outgrowths of cells from these areas merged together to regenerate the skin layer. Wound healing (re-epithelialization) in the palms of hands was primarily driven by cell proliferation of sweat gland cells, because the palms do not contain hair follicles.

The findings suggest that wound healing and regeneration of damaged skin may be an important function of cells that reside within human eccrine sweat glands. The study did not quantify the exact contribution of the sweat glands to the wound healing process or compare it with the contributions of other cell types. It also did not address whether the sweat production itself regulates or facilitates the repair process. This would be an intriguing possibility, because we all know how our palms become sweaty when we are under stress. Is it possible that the eccrine sweat production is a way of preparing the body for potential wounds and the need for repair or regeneration? Is there a way to enhance the wound healing emanating from the eccrine sweat glands? These and other questions will need to be addressed in future studies.

In summary, the work by Rittié and colleagues presents an important new perspective on how sweat glands can participate in wound healing. It is also an important reminder of how some animal models of wound healing may have their limitations when their results are translated to the human setting. Most laboratory animals that are used for wound healing studies do not have eccrine sweat glands. Results derived from such animal wound healing studies may thus not be readily applicable to the human setting and should be interpreted with a grain of sweat (salt).